Missouri Attorney General Eric Schmitt spoke about the state’s lawsuit against opioid manufacturers at the summit. Jessica Karins Daily Express
The second Adair County Opioid Summit began Monday with a simple statement from Adair County Health Department Administrator Jim LeBaron: “Opioid use is alive and well in Adair County.”
According to the Missouri Department of Health and Human Services, there were eight deaths due to opioid use in Adair County between 2013 and 2017. That equates to a rate of approximately 6.29 deaths per 100,000 people — a rate that puts Adair in about the center of the state, far lower than urban areas with rates like 41.8 deaths per 100,000 people in St. Louis County.
In the same period, 51 people in Adair County visited the emergency room due to symptoms of opioid misuse.
Ron Stewart, who represents the Adair County Health Department in the Adair County Opioid Coalition, said there are still questions to be answered about the scope of the local problem. While the Health Department knows there have been a number of opioid overdoses in the county, they do not know in which direction the statistics are trending.
“We don’t know if that number’s going to rise, if it’s going down,” Stewart said.
Local leaders are working to fight opioid misuse in the county. The Adair County Ambulance Department has also increased its efforts, not only by carrying naloxone, a medication which can reverse the effects of opioid overdose, but by increasing the mental health training of personnel.
“The ambulance wasn’t always proactive in the situation. We were very reactive,” ACAD’s Director of Program Development Kat Probst said at the summit. “We got called at the worst times for these patients. Now it’s our job to go out there and become proactive.”
Probst said it is now ACAD’s mission to make sure that patients experiencing a mental health emergency, including an overdose, get in touch with the right resources the first time they are in a crisis.
Kathy Hoppe, the vice president of integrated health services at Preferred Family Healthcare, said the provider has changed its approach to patients with opioid use disorder. It now uses the “medication-first model,” which gives people access to medication-assisted treatment as quickly as possible without first conducting long assessments or therapy sessions.
Medication-assisted treatment is a treatment for opioid addiction which provides patients with drugs that suppress cravings for opioids, but do not provide a high. Prescriptions can include buprenorphine and methadone. Other principles of the model, as outlined by Missouri Opioid STR, include providing medication without tapering or time limits, offering social services or therapy but not as a condition for continuing medication and discontinuing medication only if it is worsening the patient’s condition.
Hoppe said PFH is also refraining from assuming one size fits all in treatment for opioid addiction.
“Just because we used to keep someone 30 days doesn’t mean that’s the best thing for them anymore,” Hoppe said. “Just because we used to discharge someone in six months doesn’t mean they’re not doing well if they stay with us a year, or two, or however long they need to.”
State leaders at the summit also emphasized the importance of medication in treating opioid addiction. Among them was Dean Linneman, director of the division of regulation and license for the Missouri Department of Health and Senior Services.
Linneman said MAT should be viewed similarly to psychiatric medication. Experts in the field frequently use the term opioid use disorder rather than addiction and refer to those with OUD as patients rather than addicts, emphasizing the medical nature of the problem.
“I think every person that comes into treatment should be screened and assessed for whether medication should be helpful,” Linneman said. “Just like every person with schizophrenia, every person with major depressive disorder, with bipolar disorder ought to be screened for medication when they come into treatment, don’t you think? And then given that medication if it will save their lives.”
MAT remains more accessible for those in urban areas than for rural populations. While several physicians in Adair County are licensed to prescribe buprenorphine, the nearest methadone clinic is in Hannibal.
Other local leaders are taking steps to assist with the problem as well. Adair County Sheriff Robert Hardwcik said his office’s drug take-back program, which allows people to drop off unused and unwanted prescription medicine, has collected over 4,000 pounds of pills since it began in 2010.
Hardwick said the drugs he most frequently encounters people abusing are prescription medications, fentanyl patches (a treatment intended for chronic pain which is placed on the skin and distributes the drug gradually, similar to a nicotine patch), methamphetamine and marijuana. He said the inmates he encounters who are drug users come from all age groups.
“There’s been several deaths that have occurred in this area from opioids, and that’s a sad thing,” Hardwick said. “You need drug courts, you need support systems in place for that. You need checks and balances through case management, through the court system and through law enforcement.”
Hardwick, who has served on drug courts in the past, said more funds should be put toward the courts and providing support systems for those who struggle with addiction and may not have one.
“You need structure, you need organization, you need a purpose in life, you need to have a job,” Hardwick said. “You need to be a productive person in society to benefit yourself and benefit your family. It’s a sad thing to say that some of the people that get into these situations don’t have that. They were never given that opportunity.”
One state project focused on the medication-driven approach to addiction treatment is the Missouri Opioid-Heroin Overdose Prevention and Education Project. MO-HOPE is a partnership between the Missouri Department of Mental Health, Missouri Institute of Mental Health and the National Council on Alcohol and Drug Abuse. The project is focused on reducing opioid overdose deaths, mostly through increasing availability and awareness of naloxone.
Brandon Costerison is a public education specialist at NCADA who works with MO-HOPE. Costerison said while rates of opioid abuse in Missouri are highest in large cities, rural areas tend to see higher rates of death due to the relative lack of resources.
That’s part of what MO-HOPE is trying to change by training law enforcement agencies and first responders.
Costerison said many people who use heroin, also an opiate, start out with prescription drugs. The National Institute on Drug Abuse found that while most prescription drug users do not use heroin, heroin use is 19 times higher among those who have previously used prescription painkillers non-medically than those who have not.
In 2016, a National Safety Council survey found that 99 percent of doctors prescribed patients more than the recommended limit of a three-day dosage of opioid painkillers after a surgery or injury, and nearly one-quarter gave out month-long prescriptions. Taking opioids for a month is enough to change a patient’s brain chemistry and jump-start an addiction.
Missouri is currently the only state in the nation without a prescription drug monitoring program, which tracks prescriptions of controlled substances and can provide health authorities with important information about doctors who prescribe unusually high numbers of opioids.
Proposed state legislation, the Narcotics Control Act, could have changed that. A bill creating a PDMP passed the House, but was held up in the Senate by the Conservative Caucus, which includes Sen. Cindy O’Laughlin (R-18). The caucus’ members filibustered the bill until it was laid aside.
O’Laughlin wrote in a legislative column that she opposes the legislation because some states with PDMPs have worse drug problems than Missouri and because of concerns about potential cybersecurity breaches leading to the release of private medical information.
The bill would not make it mandatory for doctors and pharmacists to enter their prescribing information, but it would be mandatory for them to check the database before prescribing opioids to any patient.
Linneman said even a PDMP which is not mandatory would be an effective tool in fighting opioid abuse. Costerison said awareness of how to prevent opioid addiction is increasing among physicians, but some doctors are still prescribing too much.
“We know that over-prescribing still happens,” Costerison said, “but without a PDMP it’s hard to tell.”
In absence of a statewide system, St. Louis has set up its own PDMP and allowed counties from around Missouri to voluntarily join. Approximately 80 percent of Missouri residents live in areas that are covered by that system, but Adair County does not participate.
Adair County Presiding Commission Mark Shahan said the commission has considered joining that program, but was holding back for now because it was optimistic a statewide PDMP will be passed in the current legislative session.
Missouri Attorney General Eric Schmitt attended the summit to discuss Missouri’s lawsuit against opioid manufacturers. Under Schmitt’s predecessor, now-Sen. Josh Hawley, Missouri became the third state to file a lawsuit against major drug companies for misrepresenting the effects of opioids.
The defendant companies, Purdue Pharma, Johnson & Johnson, and Endo International, are accused of engaging in deliberate fraud to hide from doctors and the public the extent to which opioids are addictive. Schmitt said the lawsuits across the county are largest of their kind since the major lawsuits against tobacco companies in the 1990s, which were filed by 46 attorneys general.
The Missouri case is scheduled to go to trial in January 2021.
“We’re preparing as though it’s going to go to trial and we’re going to win,” Schmitt said.
Schmitt said the lawsuit aims to prove damages against both the state’s Medicaid system and individuals around the state. His office has set up a website, realopioidpain.com, which allows Missourians to submit personal stories of being affected by opioids. The testimonials may be used as part of the state’s case against the manufacturers.
Changing the stigma
Other participants at the opioid summit discussed approaches to facing the crisis that were more social than medical or legal. Nora Bock, deputy director for community treatment at the Missouri Department of Mental Health, said discussions of opioid use should avoid terms like “junkie,” “addict” and “abuser.”
“We don’t call individuals with diabetes ‘sugar junkies’ or ‘sugar addicts,’” Bock said. “We need to talk about it as what it is, and while many individuals made a decision to use medication or drugs, if you are in this room and never made a bad mistake that could have come back in and bit you in the (butt) really hard, raise your hand.”
No hands were raised.
Bock said young people are particularly vulnerable to both addictions and bad judgement because of their incomplete brain development.
Two other speakers at the event, Jim Marshall and David Stoecker, know that firsthand. Stoecker is a person in recovery who now works with the Missouri Recovery Network, while Marshall’s teenage son, Cody, died of an opioid overdose in 2011. Marshall founded the organization Cody’s Gift to help increase education on opioids and drug abuse prevention.
Stoecker spoke about his history of childhood abuse and how he used a succession of different drugs to cope.
“I never once had a drug problem. I had a drug solution. Unaddressed trauma, that was my problem,” Stoecker said.
He and Marshall advocate for increasing awareness of both the signs of drug abuse in young people and the root causes, which Marshell said can include childhood trauma, pressure to succeed in school and the stresses of social media.
Marshall and Stoecker helped create “Not My Child,” a documentary about parents of children struggling with addiction.
Marshall said parents should know that “addiction is not a moral failure,” either for themselves or for their children. When parents focus on that, he said, they overlook the signs because they believe it could never happen to their children.
“Don’t look for scapegoats,” Marshall said. “Look for resources.”